Provider Demographics
NPI:1407836448
Name:ELYRIA FOOT CLINIC INC.
Entity Type:Organization
Organization Name:ELYRIA FOOT CLINIC INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:COSTARAS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:440-366-6029
Mailing Address - Street 1:1170 E BROAD ST
Mailing Address - Street 2:SUITE 104
Mailing Address - City:ELYRIA
Mailing Address - State:OH
Mailing Address - Zip Code:44035-6351
Mailing Address - Country:US
Mailing Address - Phone:440-366-6029
Mailing Address - Fax:440-366-6064
Practice Address - Street 1:1170 E BROAD ST
Practice Address - Street 2:SUITE 104
Practice Address - City:ELYRIA
Practice Address - State:OH
Practice Address - Zip Code:44035-6351
Practice Address - Country:US
Practice Address - Phone:440-366-6029
Practice Address - Fax:440-366-6064
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-17
Last Update Date:2010-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHEL9267331Medicare ID - Type UnspecifiedMEDICARE ID NUMBER
OH0966970001Medicare NSC